Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease

Article (PDF Available)inEffective clinical practice: ECP 4(6):256-62 · November 2000with2751 Reads
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Abstract
For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases. To evaluate outcomes of a chronic disease self-management program in a real-world" setting. Before-after cohort study. Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data. The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building. Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires. At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant. We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.
256
© 2001 American College of Physicians–American Society of Internal Medicine
ORIGINAL ARTICLE
KATE R. LORIG, RN, DRPH
Stanford University School of
Medicine
Stanford, Calif
DAVID S. SOBEL, MD, MPH
Kaiser Permanente Northern
California
Oakland, Calif
PHILIP L. RITTER, PhD
DIANA LAURENT, MPH
Stanford University School of
Medicine
Stanford, Calif
MARY HOBBS, MPH
Kaiser Permanente Northern
California
Oakland, Calif
Eff Clin Pract. 2001;4:256-262.
Edited by John D. Birkmeyer,
MD
This paper is available at ecp.acponline.org.
Effect of a Self-
Management Program
on Patients with
Chronic Disease
CONTEXT. For patients with chronic disease, there is growing interest in “self-man-
agement” programs that emphasize the patients’ central role in managing their ill-
ness. A recent randomized clinical trial demonstrated the potential of self-manage-
ment to improve health status and reduce health care utilization in patients with
chronic diseases.
OBJECTIVE. To evaluate outcomes of a chronic disease self-management program in a
“real-world” setting.
STUDY DESIGN. Before–after cohort study.
PATIENTS AND SETTING. Of the 613 patients from various Kaiser Permanente hospitals
and clinics recruited for the study, 489 had complete baseline and follow-up data.
INTERVENTION. The Chronic Disease Self-Management Program is a 7-week, small-
group intervention attended by people with different chronic conditions. It is taught
largely by peer instructors from a highly structured manual. The program is based
on self-efficacy theory and emphasizes problem solving, decision making, and confi-
dence building.
MAIN OUTCOME MEASURES. Health behavior, self-efficacy (confidence in ability to deal
with health problems), health status, and health care utilization, assessed at baseline
and at 12 months by self-administered questionnaires.
RESULTS. At 1 year, participants in the program experienced statistically significant
improvements in health behaviors (exercise, cognitive symptom management, and
communication with physicians), self-efficacy, and health status (fatigue, shortness of
breath, pain, role function, depression, and health distress) and had fewer visits to the
emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared
with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer out-
patient visits to physicians and fewer days in hospital, but the differences were not
statistically significant. Results were of about the same magnitude as those observed
in a previous randomized, controlled trial. Program costs were estimated to be about
$200 per participant.
CONCLUSIONS. We replicated the results of our previous clinical trial of a chronic dis-
ease self-management program in a “real-world” setting. One year after exposure to
the program, most patients experienced statistically significant improvements in a
variety of health outcomes and had fewer ED visits.
B
ecause of the large impact of chronic disease on health status and health care
expenditures, there is growing interest in self-management programs.
1, 2
Such
programs emphasize the patient’s central role in managing their illness. Self-man-
agement programs aim to help patients with medical
management, maintaining life roles, and managing neg-
ative emotions, such as fear and depression. In addition,
programs provide patients with the necessary knowl-
edge, skills, and confidence (self-efficacy) to deal with
disease-related problems. Finally, self-management pre-
pares patients to collaborate with their health care pro-
fessionals and the health care system.
Recently, we documented improved health status
and decreased health care utilization in patients ran-
domized to a self-management program called the
Chronic Disease Self-Management Program
(CDSMP).
3
This program consisted of a 17-hour course
delivered over 7 weeks to patients with a variety of
chronic illnesses. The focus of the course was the day-to-
day self-management of symptoms common to chronic
diseases. At 6 months, patients enrolled in CDSMP
demonstrated improved health behaviors and health
status, as well as fewer visits to the hospital or clinic.
Despite the promising results in this trial, however, the
effectiveness of self-management has not been evaluated
in the context of “real-world” clinical practice. In this
paper, we present the 1-year outcomes of an effective-
ness study of the CDSMP as implemented by Kaiser
Permanente in 1998.
Methods
Sites
In 1997, health education departments from all 11
Kaiser Permanente regions were invited to implement
the CDSMP. Nine regions chose to participate in train-
ing designed to prepare personnel to teach the CDSMP,
to teach others how to teach the program, and to learn
how to administer the program in their regions, and six
regions participated in the current study. In addition,
Group Health Cooperative of Puget Sound formed an
affiliation with Kaiser and also participated. Each par-
ticipating region offered the CDSMP in 1 or more sites,
for a total of 21 sites: 8 in Northern California, 6 in
Southern California, 1 in North Carolina, 1 in Ohio, 1 in
Georgia, 3 in Colorado, and 1 at Group Health
Cooperative in Seattle. These 21 sites convened a total of
68 CDSMP classes. The study was approved by the insti-
tutional review boards of Stanford University and each
participating region of Kaiser Permanente.
Participants
At each site, patients were recruited to the CDSMP
when identified by their physicians or case managers
and through announcements in waiting rooms and in
health plan newsletters. In one region, letters were sent
to high utilizers identified from the automated medical
record. To participate in the program, patients had to
be older than 18 years of age, have one or more chronic
diseases, and be physically able to attend a seven-session
program. When patients arrived for the first session of
the CDSMP they were asked to participate in the eval-
uation of the program. Patients who gave informed
consent completed the baseline questionnaire and
received follow-up questionnaires by mail at 6 and 12
months. The 13% of patients who did not attend the
first session or declined to complete the first question-
naire continued in the CDSMP without participating in
the study.
Intervention
The CDSMP is based on experience with the Arthritis
Self-Management Program.
4, 5
Each class consisted of 8
to 20 participants of various ages and diagnoses, plus
interested family members. Each class was led by a pair
of educators who had received 20 hours of training.
Fifteen percent of the classes were taught by a pair of
professional leaders, 43% by a pair of peer leaders, and
42% by one leader who was a health professional and
one who was a peer. Class leaders followed a detailed
manual to teach the CDSMP.
6
Topics covered in the
CDSMP are included in Table 1. The course content has
been published in Living a Healthy Life with Chronic
Conditions, which served as a reference book for partici-
pants.
7
The program is based on self-efficacy theory and
incorporates skills mastery, reinterpretation of symp-
toms, modeling, and social persuasion to enhance a sense
of personal efficacy (i.e., confidence in one’s ability to
manage different aspects of one’s health functioning).
8
Self-efficacy has been shown to be a common pathway
through which psychosocial programs can affect health
outcomes.
8
The course includes guided mastery of skills
through weekly “action planning” and feedback of
progress, modeling of self-management behaviors and
problem-solving strategies, and social persuasion
through group support and guidance for individual self-
management efforts.
Outcome Measures
Four primary classes of outcomes were assessed: health
status, health behaviors, perceived self-efficacy, and
health services utilization. All data were collected using
self-administered questionnaires.
Health Status
Measures included self-rated health (using a scale from
the National Health Interview Survey),
9
disability (a
modified version of the Health Assessment Question-
naire disability scale),
10, 11
and health distress (a slightly
Effective Clinical Practice November/December 2001 Volume 4 Number 6
257
modified version of the Medical Outcome Study health
distress scale).
12
The health distress scale assesses the
amount of time the patient has been distressed about
health (e.g., discouraged, worried, fearful, frustrated by
health problems). Illness intrusiveness was measured by
using a previously developed index that assesses the
impact of disease on multiple aspects of one’s daily life:
physical well-being and diet, work and finances, marital
stability, sexual and family relations, recreation and social
relations, and other aspects of life.
13
Shortness of breath,
pain, and fatigue were assessed by using visual numerical
scales developed for this study. These scales are based on
the more commonly used visual analogue scales,
14,15
but
differ from the visual analogue scales in that they consist
of 10 bars of different heights and different intensity of
shading. When the visual analogue pain scale and the
visual numerical pain scale were compared (in a popula-
tion of Spanish-speaking arthritis patients), the correla-
tion was r = 0.72. The 2-week test–retest reliability of the
visual numerical version was 0.64.
15
Health Behaviors and Self-Efficacy
Measures of health behavior and self-efficacy included
frequency of exercise, cognitive symptom management,
and communication with physician health care
providers. These were developed and tested for the orig-
inal CDSM study and have been described elsewhere.
16
Health Services Utilization
Four types of health care utilization were assessed: visits
to physicians, visits to hospital emergency departments
(EDs), number of hospitalizations, and number of nights
spent in a hospital. In a previous study, self-reported uti-
lization for all Northern California Kaiser Permanente
members (n = 216) who participated in the CDSMP
during the last 6 months of 1995 were validated against
computerized medical records and medical charts.
3
Self-
reported outpatient physician visits, including emer-
gency room visits, were well correlated with visits
recorded in the computerized medical record (r = 0.70).
Patients tended to underreport recorded visits by 17%
when compared with the computerized medical records.
Conversely, the computer records sometimes had visits
recorded that were incorrectly classified. For days in the
hospital, medical records data correlated even more
highly with patient self-report (r = 0.83). Reporting dis-
crepancies were similar over time, which lessened the
concern that reporting errors biased study results.
17
It
should be noted that for the present study, self-reported
data may well be more valid than computerized records,
as 33% of the participants reported receiving some of
their care outside of Kaiser Permanente.
Analysis
Paired t-tests were used to assess changes in outcome
measures (health status, utilization, health behaviors,
and self-efficacy) between baseline and 1 year. We used
analysis of covariance to determine if health status and
health care utilization outcomes differed among the
programs taught by two peer leaders; two professional
leaders; or a mixed pair of leaders, one of whom was a
peer and the other a professional. These analyses were
done by controlling for demographic variables and base-
Effective Clinical Practice November/December 2001 Volume 4 Number 6
258
TABLE 1
Description of the Chronic Disease
Self-Management Program
OVERVIEW
Number of sessions
Length of each session
Number of leaders
Mean number of persons per program
Mean attendance per person
TOPICS
Overview of self-management and
chronic health conditions
Making an action plan
Relaxation/cognitive symptom
management
Feedback/problem solving
Anger/fear/frustration
Fitness/exercise
Fatigue management
Healthy eating
Advance directives
Communication
Medications
Making treatment decisions
Depression
Informing the health care team
Working with health care
professionals
7
2.5 hours
2
9.4 (range 4–18)
5.3 sessions
Effective Clinical Practice November/December 2001 Volume 4 Number 6
259
line status of each outcome variable. Bonferroni correc-
tions were also conducted for this last analysis to account
for multiple comparisons.
Results
During the 1998 calendar year, 68 CDSM programs
were offered in seven participating regions to a total of
703 patients (Figure 1). Six hundred thirteen patients
(87%) completed the informed consent, attended one or
more classes, and completed baseline questionnaires.
Eighty percent of the patients (n= 489) completed 1-year
questionnaires. There were no significant differences in
the noncompletion rate by region. Patient characteristics
are summarized in Table 2.
At 1 year, there were statistically significant
improvements in seven of the nine health status mea-
sures: fatigue, shortness of breath, pain, social activity
limitation, illness intrusiveness, depression, and health
distress (Table 3). However, there were no significant
differences from baseline in either self-rated health or
disability. Participation in CDSMP was also associated
with improvements in all health behaviors (exercise,
cognitive symptom management, and improved com-
munications with physicians) and in self-efficacy. There
was a statistically significant reduction in the number of
visits to EDs (0.1 fewer; P <0.05) and trends toward
fewer visits to physicians (0.4 fewer; P = 0.19) and fewer
days in the hospital (0.5 fewer; P = 0.12).
703 patients recruited
for CDSMP at 21 sites
613 patients completed baseline survey
Southern California (n = 234)
Northern California (n = 204)
Group Health Cooperative (n = 83)
Colorado (n = 36)
Ohio (n = 21)
Georgia (n = 18)
North Carolina (n = 17)
489 completed follow-up
survey at 1 year
90 declined to participate in the study
124 did not complete follow-up survey
14 died
5 too ill
21 did not finish the course
3 declined to complete the follow-up survey
2 lost to follow-up
79 gave miscellaneous reasons
FIGURE 1. Study patients. CDSMP =
Chronic Disease Self-Management
Program.
TABLE 2
Baseline Demographic Characteristics of
Patients
CHARACTERISTICS
Mean age, yr
Male
Education (mean), yr
Married
Non–Hispanic white
Mean number of chronic diseases
Chronic disease
Lung
Heart
Diabetes
Arthritis
PATIENTS
(n = 613)
62.2 years
27%
14.3 years
64%
83%
2.3
21%
24%
26%
42%
Effective Clinical Practice November/December 2001 Volume 4 Number 6
260
We conducted 19 analyses to determine if the sta-
tus of the leaders (two peer, two professional, and one
peer/one professional) affected health behavior, health
status, or health care utilization outcomes. After cor-
recting for multiple comparisons, we found no signifi-
cant differences. Thus, it appears that CDSMP out-
comes are the same whether the program is led by peers
or professionals.
Discussion
We found that patient use of CDSMP was associated
with better outcomes in all study domains—small but
statistically significant improvements in health status,
health behavior, and self-efficacy and less use of the ED.
In this effectiveness study, participants were not recruit-
ed as “study participants,” nor were the programs given
in a controlled study environment. Thus, our findings
should be indicative of outcomes achievable in a “real-
world” health care setting.
It is important to acknowledge several limitations
in our study. First, given the before–after design, it is
possible that the results obtained were not caused by the
CDSMP. In fact, our results were similar to those of our
previous randomized trial for the nine outcome vari-
ables common to both studies.
3
A second concern
involves dropouts. Approximately 20% of study patients
dropped out by 1 year. These patients were younger and
*A lower score is better.
A higher score is better.
Participants were asked to report utilization in the 6 months preceding the follow-up survey.
TABLE 3
Changes at 1 Year in Health Status, Health Behaviors, Self-Efficacy, and Health Care Utilization
VARIABLE
Health status*
Disability (0–3)
Health distress (0–5)
Social/role activity limitation (0–4)
Illness intrusiveness (1–7)
Fatigue (1–10)
Shortness of breath (1–10)
Pain (1–10)
Self-rated health (1–5)
Depression (0–3)
Health behaviors
Aerobic exercise (min/wk)
Range-of-motion exercise (min/wk)
Cognitive symptom management (0–3)
Communication with physician (0–5)
Self-efficacy (1–10)
Health care utilization
Physician visits (n, past 6 mo)
Emergency department visits (n, past 6 mo)
Hospitalizations (n, past 6 mo)
Days in hospital (past 6 mo)
BASELINE MEAN ± SD
(n = 489)
0.4 ± 0.4
2.3 ± 1.3
2.0 ± 1.1
3.3 ± 1.4
5.8 ± 2.5
3.3 ± 3.0
5.2 ± 3.0
3.3 ± 0.9
1.3 ± 0.6
87 ± 94.7
35 ± 49.2
1.3 ± 0.9
2.9 ± 1.2
5.2 ± 2.2
5.5 ± 6.0
0.4 ± 0.9
0.2 ± 0.6
1.2 ± 5.9
12-MONTH CHANGE
MEAN ± SD
(n = 489)
0.0 ± 0.3
–0.3 ± 1.2
–0.2 ± 1.0
–0.2 ± 1.2
–0.3 ± 2.4
–0.3 ± 2.5
–0.3 ± 2.5
0.04 ± 0.8
–0.1 ± 0.5
13 ± 97.3
9 ± 55.8
0.4 ± 0.9
0.2 ± 1.0
0.5 ± 2.4
–0.4 ± 7.2
–0.1 ± 1.0
–0.1 ± 0.7
–0.5 ± 7.3
P VALUE
0.77
0.001
0.001
0.001
0.002
0.003
0.03
0.20
0.001
0.01
0.001
0.001
0.001
0.001
0.19
0.05
0.14
0.12
more likely to be nonwhite and unmarried (all P <0.05).
In addition, the impact of illness on their self-reported
health was higher, they had higher activity limitations,
and they made more doctor and ED visits at baseline (all
P <0.05). For these reasons, we repeated our analyses,
carrying forward the last data collected, either baseline
or 6 months. The only difference between this and the
original analysis was that the trend toward fewer visits
to physicians was stronger (P = 0.08).
Finally, as in all studies involving human patients,
these participants were volunteers. Thus, the effects of
this intervention can only be extrapolated to patients
willing to take part in a 7-week group intervention. We
have several indications that this may be a sizable per-
centage of the population with chronic illnesses.
Glasgow and Toobert
18
found that 40% of the diabetics
in a group practice, when asked to participate, took part
in a diabetes education program. Initially, most recruit-
ment for the present study was centered on securing
referrals from health professionals. More recently,
recruiting for the CDSMP within Kaiser Permanente
has been done largely through letters to panels of
patients with targeted diseases. The acceptance rate with
a single letter has been 5% to 10%.
Implementation of CDSMP may substantially
reduce health care costs. Over the 1-year period, study
participants had a mean of 0.97-day reduction in hospi-
talization (P = 0.08). This includes –0.45 days change in
the first 6 months (data not shown in tables), plus –0.52
in the second 6 months (Table 3). They also averaged 0.2
fewer ED visits (P = 0.01) (–0.11 in the first 6 months
plus –0.09 in the second 6 months). Taking $1000 as an
average cost per hospital day and $100 for the average
cost of an ED visit, the expected savings would be $990
per participant in the first year. The cost of the inter-
vention within the Kaiser Permanente system (includ-
ing leaders’ training, materials, and administration) is
approximately $200 per participant. If these changes are
real, the savings for the 489 patients who completed the
study were nearly $400,000, or a 1:4 cost-to-savings ratio.
This suggests that the program may more than pay for
itself.
With growing recognition of the effectiveness of
CDSMP, enrollment in the program in Kaiser
Permanente had increased to 2500 participants in the
year 2000. Further expansion of the program appears to
be limited as much by system capacity (e.g., group lead-
ers, space, scheduling) as by patient interest. Because
most patient education interventions are disease-specif-
ic, it takes additional time and effort to recruit patients
to our more generic program. However, we believe that
the benefits likely to be achieved by self-management
justify the energy and resources required to implement
the programs.
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Effective Clinical Practice November/December 2001 Volume 4 Number 6
261
For patients with chronic disease, there is growing
interest in “self-management” programs, which
emphasize the patients’ central role in managing their
illness.
Although a randomized clinical trial has suggested
the efficacy of self-management, we sought to examine
the effectiveness of such programs in actual practice.
We reported the effects of a Chronic Disease Self-
Management Program on health status and resource
use in 489 managed care patients.
Patients enrolled in the self-management program
experienced small but statistically significant
improvements in health status, health behaviors, and
self-efficacy. In addition, patient use of the program was
associated with fewer emergency department visits.
Because both efficacy trials and “real-world” studies
suggest their effectiveness, health systems should
consider implementing self-management programs
for patients with chronic conditions.
Take-Home Points
Effective Clinical Practice November/December 2001 Volume 4 Number 6
262
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13. Devins G, Mandin H, Hons R, et al. Illness intrusiveness and
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15. González V, Stewart A, Ritter P, Lorig K. Translation and val-
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Rheum. 1995;38:1429-46.
16. Lorig K, Stewart A, Ritter P, González V, Laurent D, Lynch J.
Outcome measures for health education and other health care
interventions. Thousand Oaks, CA: Sage Publications; 1996.
17. Ritter P, Lorig K, Stewart A, Sobel D, Bloch D. Self-reports of
health care utilization compared to provider records. J Clin
Epidemiol. 2001;54:136-41.
18. Glasgow RE, Toobert DJ. Brief computer assisted diabetes
dietary self-management: effects on behavior, physiologic out-
comes and quality of life. Med. Care 2000; revision submitted.
Acknowledgment
The authors would like to acknowledge the assistance of Jayna
Rogers, Teresa Baylon, Virginia González, the Kaiser Permanente
regional health education directors, regional project coordinators,
site coordinators, trainers, and leaders. Further information is
available on the website: www.stanford.edu/group/perc/.
Grant Support
This project was supported in whole or in part by the Kaiser
Foundation Research Institute and the Garfield Memorial Fund.
Correspondence
Kate R. Lorig, DrPH, Stanford Patient Education Center, 1000
Welch Rd., Suite 204, Palo Alto, CA 94304; telephone: 650-723-
7935; fax: 650-725-9422; e-mail: lorig@stanford.edu.
    • "Several studies have highlighted that higher PE positively influences disease management leading to improvement of health behaviors [32] [33] [34] [35] "
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    • "The researcher discussed diabetes management strategies and evaluated and updated the action plan with the participants at each intervention visit. This problem-based, patient-focused approach was consistent with nursing case management and diabetes self-management interventions (Lorig, Ritter, & Gonzales, 2003; Lorig et al., 2001). The collaborative action plan included the identified health issues and behavior change strategies to manage diabetes. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: The study purpose was to evaluate the feasibility of a chronic disease self management/case management intervention for adults experiencing homelessness and diabetes and the ability to retain subjects. Methods: Participants with type 2 diabetes were recruited at a homeless clinic and a subset received the intervention. Analysis included calculating a retention rate and evaluating the intervention implementation process. Results: Of the nine participants, five were retained for 12 weeks and two of three participants completed the full intervention. Conclusions: Study retention is feasible for adults experiencing homelessness. Further intervention refinement is needed to address relevancy of content and time constraints.
    Full-text · Article · Oct 2014
    • "This The significance of self-care and selfmanagement to optimise treatment and prevent further disease progression is extremely important. There is an emergent body of evidence suggesting that, when compared with no intervention (e.g. standard care), selfmanagement approaches can provide benefits for participants by increasing knowledge, performance of self-management behaviours and self-efficacy (Lorig et al, 2001; Barlow et al, 2002), with a decrease in the need for unplanned care (Lorig et al, 2001; Purdy, 2010). Living with a long-term condition such as COPD, and managing symptoms and self-care, can be impeded by the development of depression, resulting in the exacerbation of physical symptoms and emotional distress (Wright et al, 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: People with chronic obstructive pulmonary disease (COPD) have a high prevalence of anxiety and depression, which can have an impact on their symptoms and the way they manage their condition. Intervention that takes psychological distress into account may lead to better outcomes than simple advice-giving. Aim: To explore the feasibility of integrating psychological screening and intervention into nurse-led reviews of patients with COPD. Method: Nurses were given training on a pathway developed for patients with COPD. This included screening for depression and anxiety and assessing their severity; providing self-management education by means of a motivational approach; and offering pulmonary rehabilitation. Results: The nurses' level of confidence increased following training. Patients were accepting of the screening process and felt more able and motivated to manage their condition after the intervention. Eleven of the 35 patients that took part in the study period had evidence of anxiety and/or depression. Out of a total of 16 patients eligible for pulmonary rehabilitation, 12 agreed to referral. Of these, three patients were seen by their GP, one was started on antidepressants, and one was referred to the psychology service. Conclusion: Training practice nurses to screen for depression and anxiety, and to offer self-management education using a motivational interviewing approach, increased the reported capability and motivation of patients with COPD to manage their condition. It may also improve the uptake of pulmonary rehabilitation. Use of this pathway does not place a burden on other care providers or greatly increase prescribing costs.
    Full-text · Article · Aug 2014
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